The Princess and the Pea Graft—A Solid Cartilaginous Tip Graft for Noses with Thick Skin Envelope

Abstract

Introduction

Thick skin-soft tissue envelope (SSTE) and weak cartilage make nasal tip definition challenging in many Asian rhinoplasty patients.

Objectives & Hypotheses

We aimed to assess whether the Princess and the Pea (PP) graft–a solid, conical costal cartilage tip graft–can improve tip projection and definition in thick-SSTE patients. We hypothesized that it would yield reliable aesthetic and functional results with minimal complications.

Study Design

Prospective clinical study with 12-month postoperative follow-up.

Methods

Sixty patients of East, South, and Southeast Asian descent received a PP graft anchored to the lower lateral cartilages. Outcomes were measured using SCHNOS and a 5-point Likert satisfaction scale.

Results

Mean satisfaction was 4.5/5, average SCHNOS score 0.54, and no graft-related complications occurred.

Conclusion

The PP graft is a safe and effective method for enhancing nasal tip projection and definition in thick-SSTE patients.

Keywords

nasal tip definition - Princess and the Pea graft - cap graft - open rhinoplasty - Asian rhinoplasty

Publication History

Received: 06 November 2025

Accepted: 03 December 2025

Article published online:
05 January 2026

• References

• 1 Sheen J. Aesthetic Rhinoplasty. 2nd ed.. St. Louis, MO: C.V. Mosby Co.; 1987
• 2 Toriumi DM. Nasal tip contouring: Anatomic basis for management. Facial Plast Surg Aesthet Med 2020; 22 (01) 10-24
• 3 Baker SR. Suture contouring of the nasal tip. Arch Facial Plast Surg 2000; 2 (01) 34-42
• 4 Çakır B, Öreroğlu AR, Daniel RK. Surface aesthetics in tip rhinoplasty: A step-by-step guide. Aesthet Surg J 2014; 34 (06) 941-955
• 5 Jang YJ, Yu MS. Rhinoplasty for the Asian nose. Facial Plast Surg 2010; 26 (02) 93-101
• 6 Ng CL, Uppal S, Jung DH, Loh ICY. Lengthening of the Asian nose. Facial Plast Surg 2020; 36 (05) 539-553
• 7 Khoo B-C. Sculpturing the nasal tip and lobule region. Facial Plast Surg Clin North Am 1996; 4: 103
• 8 Cho GS, Kim JH, Yeo NK, Kim SH, Jang YJ. Nasal skin thickness measured using computed tomography and its effect on tip surgery outcomes. Otolaryngol Head Neck Surg 2011; 144 (04) 522-527
• 9 Ng CL. A classification system of Asian noses for rhinoplasty. Facial Plast Surg 2024; 41: 540-546
• 10 Na HG, Jang YJ. Dorsal augmentation using alloplastic implants. Facial Plast Surg 2017; 33 (02) 189-194
• 11 Wang JH, Lee BJ, Jang YJ. Use of silicone sheets for dorsal augmentation in rhinoplasty for Asian noses. Acta Otolaryngol Suppl 2007; 558 (558) 115-120
• 12 Gruber RP, Weintraub J, Pomerantz J. Suture techniques for the nasal tip. Aesthet Surg J 2008; 28 (01) 92-100
• 13 Moubayed SP, Ioannidis JPA, Saltychev M, Most SP. The 10-item Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) for functional and cosmetic rhinoplasty. JAMA Facial Plast Surg 2018; 20 (01) 37-42
• 14 Wu WTL. The Oriental nose: An anatomical basis for surgery. Ann Acad Med Singap 1992; 21 (02) 176-189
• 15 Davis RE, Hrisomalos EN. Surgical management of the thick-skinned nose. Facial Plast Surg 2018; 34 (01) 22-28
• 16 Guyuron B, Lee M. An effective algorithm for management of noses with thick skin. Aesthetic Plast Surg 2017; 41 (02) 381-387